The autopsy has become an historic tool. Pathologists are no longer trained by doing >200 autopsies as a resident. They may complete <24 autopsies and still be approved. They do not even have training wheels on their "bicycles"
4
I've been waiting a year now for the report of my husband's brain autopsy. He wouldn't have wanted it, but his sons and our daughter should know if he had Lewy Body or some other dementia. And if and when scientists know more about this awful disease, and how to treat it, it will have benefitted them and so many other families. Doctors should encourage families to allow autopsies whenever there is the possibility of gaining knowledge.
17
I am sure that, in light of the recommendation to stop PSA and other tests in annual exams, soon Medicare will eliminate all diagnostic tools for helping people live as long and in as good health as possible.
2
A. Stanton; do you have any evidence whatsoever to back up your comments?
"..they should have known, but didn't."
" I don't know whether autopsies were performed on any of them, but I doubt it."
They all may have known everything about their maladies, and all may have had an autopsy, but we don't know that. Why do you assume they didn't?
Also, re: your previous comment about avoiding autopsies for religious reasons. You do realize that this article is not advocating forcing autopsies on anyone? It is suggesting that clinicians request permission for autopsy more often than now happens.
Except in a criminal matter, religious reasons for avoiding autopsies are almost always honored.
"..they should have known, but didn't."
" I don't know whether autopsies were performed on any of them, but I doubt it."
They all may have known everything about their maladies, and all may have had an autopsy, but we don't know that. Why do you assume they didn't?
Also, re: your previous comment about avoiding autopsies for religious reasons. You do realize that this article is not advocating forcing autopsies on anyone? It is suggesting that clinicians request permission for autopsy more often than now happens.
Except in a criminal matter, religious reasons for avoiding autopsies are almost always honored.
5
Medicare's refusal to pay for autopsies is actually quite defensible on scientific grounds. Autopsy enthusiasts generally neglect to point out that the procedure produces only anecdotal information, relevant only to the case at hand. Until the day comes when all patients, or at least a random selection of them, undergo autopsy, post-mortem findings are simply isolated factoids that should not influence a physician's future behavior. For several decades my colleague physicians have pointed to the need for "evidence based" decisions instead of those rooted simply in the last patient or personal experience of the practitioner. Autopsies, even if we did many more of them, wouldn't produce an actionable data base unless the procedure is universally or at least randomly performed.
5
My father was a clinical and forensic pathologist in the 50's though 70's, when autopsies were required for hospital accreditation, and routine. This requirement should be reinstated. Weekly staff meetings about what autopsies had revealed helped the house staff improve their procedures. Cost would be lowered if autopsies were required again because they would reduce rates of morbidity and mortality, with attending expenses. If nothing else, they're a safeguard against hospital privileges for doctors who are repeatedly incompetent. The final diagnosis tells all. Autopsies also help solve medical mysteries. For example, my father diagnosed a very rare genetic heart defect in two siblings who died under what seemed like mysterious circumstances- very important information for the family involved.
19
After the war I trained in a medical school in England. For the benefit of education an autopsy (post-mortem PM in England) was demonstrated each day between morning and afternoon teaching sessions. The commonest diagnostic conclusion was GOK, shorthand for God Only Knows!
It is remarkably difficult in most instances to know why a person died. Yes, you might find abnormalities such as meconium in a neonate's lungs, but did that kill them?
There was a time in the US when meeting accreditation standards required a percentage of autopsies should be performed; in consequence there developed an ugly system in which residents were rewarded (or punished) in proportion to the number of autopsies they could persuade the bereaved families to agree to.
Most pathologists in my (substantial) experience will say that an autopsy is offensive to the relations and is only justifiable when there is a real issue at stake, usually forensic. Absence of medical purpose explains the decline of the autopsy rate, not absence of financial reward.
It is remarkably difficult in most instances to know why a person died. Yes, you might find abnormalities such as meconium in a neonate's lungs, but did that kill them?
There was a time in the US when meeting accreditation standards required a percentage of autopsies should be performed; in consequence there developed an ugly system in which residents were rewarded (or punished) in proportion to the number of autopsies they could persuade the bereaved families to agree to.
Most pathologists in my (substantial) experience will say that an autopsy is offensive to the relations and is only justifiable when there is a real issue at stake, usually forensic. Absence of medical purpose explains the decline of the autopsy rate, not absence of financial reward.
3
Many people die daily due to medical negligence. The less autopsies are performed the less of a spotlight on this malfeasance. The families of the deceased may have more or better recourse for malpractice suits. So of course the powers that be don't want autopsies done. It cuts into their profits.
So much for obtaining new medical knowledge or procedures for all.
So much for obtaining new medical knowledge or procedures for all.
14
It may be counter-intuitive but it is the physicians especially the most experienced physicians that are pushing to return to more autopsies.
The main reason that they are for the most part no longer done is cost. Medicare used to pay for them. And insurers used to follow suit.
The main reason that they are for the most part no longer done is cost. Medicare used to pay for them. And insurers used to follow suit.
10
I'm thinking states that protect hospitals and doctors at the expense of patients and their access to justice for malpractice will oppose more autopsies. The criminally negligent Florida hospital that killed my husband wanted his body gone from their premises within 6 hours of his death. It's a separate issue, but hospitals like this one should NOT be allowed to stall about releasing health records and should NOT be allowed to charge the victim's family for releasing these records to whomever the family pleases.
6
While this case highlights a natural cause of death, the need for better understanding of diagnosis-related errors cannot be overstated. Because such errors may not become apparent when they occur (e.g., a missed cancer), providers who missed that diagnosis, but were no longer involved in the patient’s care when it was eventually identified, will rarely know what they missed. While Dr. Jauhar states that “diagnostic accuracy is rarely raised as a safety issue,” we (the malpractice insurance program for the Harvard-affiliated physicians) have been extremely active over the past 10 years in sussing out what goes wrong and why. Autopsies may help, but our ultimate goal is to improve diagnostic accuracy for the living.
1
Doctors are humans. There will be missed diagnosis sometimes. Sometimes, diagnosis can be complex and a doctor will have to make a judgement based on the data at hand. Remember, doctors do not do autopsy when they are diagnosing. Also, once dead, how does it help knowing what could have been done. Just additional trauma for patient's loved ones and regret for doctors.
This practice will put too much stress on doctors and they will delay treatment in order to rule out every possible cause, even if remote.
What is important is that doctors do sincere and honest job and that if there is negligence, patients have right to request autopsy.
This practice will put too much stress on doctors and they will delay treatment in order to rule out every possible cause, even if remote.
What is important is that doctors do sincere and honest job and that if there is negligence, patients have right to request autopsy.
1
I couldn't agree more. Our pathologist offered a weekly example of an autopsy to my fourth year Medical Technologist class. We all learned how valuable this tool could be. When I learned the practice was slipping away I was saddened. I would suggest using fewer tests during life could easily balance the cost of this. During my 30 year career, I often saw tests ordered on patients en masse as if in the hopes that one of a hundred so ordered would hit a diagnosis.
7
Kind of ironic that insurance companies aren't interested in paying for autopsies. Knowing what untreated conditions patients died with that were unrelated to their deaths could drastically reduce exhaustive testing and treatment of "incidentulomas" and "abnormal" conditions that may be far more normal than we think.
7
"At the very least, Medicare and private insurers should start paying for autopsies again . . ."
Good luck with that.
Good luck with that.
1
""At the very least, Medicare and private insurers should start paying for autopsies again . . .""
Do you expect them to pay for a procedure on the dead?
Do you expect them to pay for a procedure on the dead?
1
Medical errors could result from chasing a particular diagnosis to the extreme. There are literally tons of medicines to treat high blood pressure and heart disease, obviating the need for interventions. However, tiredness as a symptom need not be cardiac in origin alone, it can result from adjoining liver disease, intestinal ulcers and so on. Treating the heart could result in ignoring other impending calamities, and may even speed up the latter. In most of the third world, this is a 90% problem as most diagnosis stops with the heart.
3
I must admit, I can bear the thought of my spouse being cremated. But no autopsy please!
2
My husband died in a fiery car crash. The coroner called to inform me that he had died instantly. I will always be grateful for the knowledge that it was only his dead body trapped in a burning car.
15
Pathologists do not receive pay for a non-forensic autopsy, which requires about four hours of professional time to fully perform and document. In the era of exquisite medical imaging and lab tests that delve into disease at the molecular level, it is rare for an autopsy to provide much more information about a patient's disease beyond what was known before death. Autopsies are completely incapable of discerning causes of death due to many "functional" diseases, such as ventricular arrhythmia, asthma, and seizure disorders.
Having practiced pathology in both academic and community settings since 1981, I have also observed that autopsy pathologists, including medical examiners, commonly assign causes of death with little regard to the scientific method. Autopsy pathology is opinion-driven 19th century medicine that has been superseded by far more sophisticated diagnostic modalities that take a rigorous scientific approach.
Having practiced pathology in both academic and community settings since 1981, I have also observed that autopsy pathologists, including medical examiners, commonly assign causes of death with little regard to the scientific method. Autopsy pathology is opinion-driven 19th century medicine that has been superseded by far more sophisticated diagnostic modalities that take a rigorous scientific approach.
13
This article made me wish again that we had performed an autopsy on my father. He died at 60 of uncertain causes after spending six weeks on a ventilator and two months in the hospital. He was perfectly healthy three months before.
24
The monolith of modern medicine is far too intellectually limited by its conflation of causality and discovery that it should never be trusted with applying autopsy in meaningful way that wouldn't result in hacking people up to prove the obvious.
3
It should be mentioned that the family can arrange and pay for an autopsy if they wish. That circumvents any reluctance for an autopsy on the part of the hospital or insurance company.
When my mother passed away, my siblings and I took that route, and are glad we did. The results gave us medical information that will be helpful in making decisions about our own healthcare.
When my mother passed away, my siblings and I took that route, and are glad we did. The results gave us medical information that will be helpful in making decisions about our own healthcare.
18
Many people have good and sufficient religious reasons for avoiding autopsies that need to be respected.
1
Just a few days ago I counted up the number of doctors I grew up with who are already dead, and there were six of them.
Clearly there were a lot of things about their own maladies they should have known but didn't. I don't know whether autopsies were performed on any of them, but I doubt it.
Clearly there were a lot of things about their own maladies they should have known but didn't. I don't know whether autopsies were performed on any of them, but I doubt it.
1
Knowing about your malady is not the key to everlasting life!
7
In my pre-retirement career, I had two trenchant experiences with autopsies.
On the bad side was the implicit and often explicit push during training for "getting the autopsy", best illustrated by the reprehensible "$1,000 gold ball" strategy I hear once. It went like this: "We are so sorry about the death of your loved one. Indeed, in our desperate urge to help, during his surgery we placed a $1,000 gold ball in his incision. It will not be reimbursed by insurance and that cost would be borne by his family but an autopsy would allow us to remove it and avoid this charge..."
On the good side was an autopsy I pushed for personally. I inherited responsibility for a patient who had been misdiagnosed before me. I was able to divine his trouble was caused by an undiagnosed serious infection which was under treatment when he suddenly died under care. His situation was confirmed at autopsy and fueled a spirited and appropriate discussion among the entire medical staff.
Autopsies help both individual doctors, patients and families and society as a whole. Knowing prostate cancer swells in an aging population with few symptoms or consequences is a direct result of autopsy data, guiding public policy to the benefit of the commonweal.
On the bad side was the implicit and often explicit push during training for "getting the autopsy", best illustrated by the reprehensible "$1,000 gold ball" strategy I hear once. It went like this: "We are so sorry about the death of your loved one. Indeed, in our desperate urge to help, during his surgery we placed a $1,000 gold ball in his incision. It will not be reimbursed by insurance and that cost would be borne by his family but an autopsy would allow us to remove it and avoid this charge..."
On the good side was an autopsy I pushed for personally. I inherited responsibility for a patient who had been misdiagnosed before me. I was able to divine his trouble was caused by an undiagnosed serious infection which was under treatment when he suddenly died under care. His situation was confirmed at autopsy and fueled a spirited and appropriate discussion among the entire medical staff.
Autopsies help both individual doctors, patients and families and society as a whole. Knowing prostate cancer swells in an aging population with few symptoms or consequences is a direct result of autopsy data, guiding public policy to the benefit of the commonweal.
12
Autopsies are frequently done poorly. Pathologists want to get autopsies "out of the way" and get back to paying work. This pressure comes from other members of the pathologist's practice, who want the biggest paychecks possible.
5
I have read at least one paper that showed that modern imaging has had little impact on the number of missed diagnoses, a real surprise. The rate of misdiagnosis as tested by autopsy before and during the CT/MRI era was the same. My best guess is that this is what happens when experts assume things to be true a priori, i.e., without testing them first. There must have been the assumption--and I hope Medicare thought it through at least that far--that newer imaging would pick up many things that had been missed. The only procedure that does that for sure is the autopsy.
17
All data is important whether it is autopsy data revealing what's going on in there at a gross, cellular or molecular level or charted patient data.
Charted data is equally important in improving future outcomes as post death data.
Why we value autopsy or post mortem donations of data or bodies and inhibit the sharing of charted patient data is a mystery preventing the improvement of outcomes in America.
https://www.linkedin.com/pulse/empowered-patient-isnt-howard-green-md?tr...
This piece
Charted data is equally important in improving future outcomes as post death data.
Why we value autopsy or post mortem donations of data or bodies and inhibit the sharing of charted patient data is a mystery preventing the improvement of outcomes in America.
https://www.linkedin.com/pulse/empowered-patient-isnt-howard-green-md?tr...
This piece
5
This article falsely implies American medicine is a science not a for profit business. There is no revenue incentive, so non forensic autopsies are only going to become more rare in our current system.
22
High medical costs-- much higher than they used to be--have pushed us into a corner of ignorance. Many things which used to be routine are not paid for now. The insurance companies rule from above. As their profits soar our health care diminishes.
Single-payer health care would reduce these costs and get us back to evidence based medicine.
Single-payer health care would reduce these costs and get us back to evidence based medicine.
16
Thank you, Dr. Jauhar, for authoring this most informative/provocative OP-ED.
15
Let me see if I got this right! A doctor in a hospital misdiagnoses a problem and because of it you die. Then to add insult to injury, you allow the hospital to further demean and abuse your body by cutting you open to find out what they did wrong. A bit late isn't it. I agree with the folks that say to bring in an outside firm for the autopsy, so there is no cover up by the hospital, that is, if you can afford it. If you can't, just chalk up the death to fate... the fate of being in the hands of an incompetent M.D.
4
No, you didn't get it right at all. You got it totally wrong. Patients die without their physicians knowing what is wrong with them- and an autopsy shows what WAS wrong with them.
Demeaning and abusing? Clearly you've never been in an anatomy lab or a post-mortem. You have no idea what you're talking about.
As an ER physician. I've presided over the deaths of more people than I can count. Very few of them were autopsied- only the deaths in which the medical examiner ordered a post-mortem exam. I wish there had been more. The knowledge obtained from the post-mortem exam of the deceased is invaluable.
What the writer doesn't mention is that much of the foundation of modern medicine is made of the knowledge gained by 19th and 20th century pathological investigators who learned a great deal from autopsies. Those clinicians were aware that they frequently still had much to learn after their patients passed away, and sought answers from autopsies. The 20th century writer who called the autopsy "the flower, no, the red rose, of medicine" knew what he was talking about.
Demeaning and abusing? Clearly you've never been in an anatomy lab or a post-mortem. You have no idea what you're talking about.
As an ER physician. I've presided over the deaths of more people than I can count. Very few of them were autopsied- only the deaths in which the medical examiner ordered a post-mortem exam. I wish there had been more. The knowledge obtained from the post-mortem exam of the deceased is invaluable.
What the writer doesn't mention is that much of the foundation of modern medicine is made of the knowledge gained by 19th and 20th century pathological investigators who learned a great deal from autopsies. Those clinicians were aware that they frequently still had much to learn after their patients passed away, and sought answers from autopsies. The 20th century writer who called the autopsy "the flower, no, the red rose, of medicine" knew what he was talking about.
67
As a physician of a certain age, I can tell you the rate of autopsies went down directly when payment went away. Every autopsy performed is done for free by our dedicated pathologists - often at the end of the day after their other duties have been completed. The hospital has to pay for the time of the aides - not to mention the laboratory work and equipment used. When I have had autopsies performed on my patients, I am gratified by how far above and beyond my pathology colleagues go to help answer the question why did this patient die and did we miss something that could have made a difference.
If we want to answer these questions routinely, we would pay for it. The societal answer is obvious.
If we want to answer these questions routinely, we would pay for it. The societal answer is obvious.
29
Dr.Jauhar,
During my Internal Medicine Residency in the early 70s the institution supplemented the pathology department for their time in performing the autopsy. And there was instruction from the institution that residents ask permission from the family for the exam. There was no charge to the family. I learned a great deal from just asking permission from the families. I learned that closure is a powerful thing, both for the family and the physician.
Later in training in radiology, I was greatly influenced by Dr. Ben Felson, who
said he learned his imaging skills in the pathology lab. Dr. Felson was a giant in thoracic radiology.
Proper medicine requires infinite attention to detail. Autopsy is an important tool in supplying that detail. Medicine needs to "look at one self".
During my Internal Medicine Residency in the early 70s the institution supplemented the pathology department for their time in performing the autopsy. And there was instruction from the institution that residents ask permission from the family for the exam. There was no charge to the family. I learned a great deal from just asking permission from the families. I learned that closure is a powerful thing, both for the family and the physician.
Later in training in radiology, I was greatly influenced by Dr. Ben Felson, who
said he learned his imaging skills in the pathology lab. Dr. Felson was a giant in thoracic radiology.
Proper medicine requires infinite attention to detail. Autopsy is an important tool in supplying that detail. Medicine needs to "look at one self".
17
Fascinating article. One question. Dr. Jauhar wrote, "Studies have found that patients at hospitals that perform more autopsies suffer fewer major diagnostic mistakes." I would be extremely interested in learning which studies demonstrate that point. I'm surprised the online version didn't link to at least one study. Will the writer please comment?
8
My best friend died in September at age 64, two days after heart surgery from which he didn't wake up. According to his housemate (whose account may not be entirely trustworthy), his doctor asked to authorise an autopsy, as he had thought my friend's chances of coming through the surgery were very good. However, my friend had suffered financial reversals and there was no money to pay for an autopsy. (I suspect my friend's chances were overestimated, as he had had a heart attack which was not his first.)
'Nonprofit' hospitals reap major donations from wealthy benefactors (at least in our area). Perhaps one of these moguls could be persuaded, instead of slapping his name on brick and mortar, to endow an autopsy program. I suspect hospitals and surgeons do not really want one, though; that the fear of autopsies turning up grounds for malpractice suits, rather than overconfidence in technology or delicacy with grieving families, is the real reason for the decline. (I can't say I've noticed oversensititivity to families....)
'Nonprofit' hospitals reap major donations from wealthy benefactors (at least in our area). Perhaps one of these moguls could be persuaded, instead of slapping his name on brick and mortar, to endow an autopsy program. I suspect hospitals and surgeons do not really want one, though; that the fear of autopsies turning up grounds for malpractice suits, rather than overconfidence in technology or delicacy with grieving families, is the real reason for the decline. (I can't say I've noticed oversensititivity to families....)
4
Families are not charged for an autopsy if the doc requests it. If there is a question and a second or outside autopsy is done by the request of then family, that is a different story.
2
Thanks, Lynn. As I noted, the housemate's account may not be entirely trustworthy, and she may have been trying to get money from me - though if she'd wanted me to pay for an autopsy, she shouldn't have shipped off his body to the undertaker. Clearly you can't autopsy on an embalmed body.
I do think endowing an autopsy program and encouraging families to allow it would be productive. If doctors can ask families to benefit society by donating their loved one's organs even before he's necessarily stopped breathing and officially kicked it, they can certainly ask for autopsies on the same rationale. Which leads one back to the money issue again, since everyone but the donor and donee makes big bucks off the organ transplant, but the only profit anyone makes from an autopsy is knowledge - and there's always that chance, as I mentioned, of turning up grounds for a malpractice suit.
I do think endowing an autopsy program and encouraging families to allow it would be productive. If doctors can ask families to benefit society by donating their loved one's organs even before he's necessarily stopped breathing and officially kicked it, they can certainly ask for autopsies on the same rationale. Which leads one back to the money issue again, since everyone but the donor and donee makes big bucks off the organ transplant, but the only profit anyone makes from an autopsy is knowledge - and there's always that chance, as I mentioned, of turning up grounds for a malpractice suit.
1
Every suicide should have an autopsy. According to The Times, Dr. Omalu, the subject of the movie "Concussion," can identify why people commit suicide simply by looking at their brains at autopsy. If he can do this, I assume other pathologists can do the same. This would obviously solve the mystery of why people commit suicide.
3
Do people facing death and the families of the deceased have any input on? Some of us- for religious and other reasons- want to die, and our bodies disposed of, without being dissected.
Are people going to need yet another advance legal directive to avoid this final medical indignity?
Are people going to need yet another advance legal directive to avoid this final medical indignity?
4
As someone who actually use to perform autopsies, I can confidently say that the vast majority that were ordered were useless, ridiculously labor intensive, and only occasionally revealed information that was unknown pre-mortem or that highlighted a diagnostic error. A focused, limited autopsy, on the other hand where the clinician or family member has a specific question(s) they want answered can be extremely useful but they should "consult" the pathologist so they do not have unrealistic expectations. Often times clinicians and lay people are uninformed about what an autopsy can and cannot address. And of course, someone has to pay for the autopsy, which had not been the case in the past.
11
If your argument is that autopsies are beneficial, and that we should do more of them, then it would be wise to avoid phrases like "splayed-out tissues" when referring to human remains.
Do I need to explain why?
Do I need to explain why?
15
No. We need to face the fact we avoid autopsies because we are squeamish about it, and "splayed out" is correct terminology. We need to do autopsies because we need an honest discussion of what happened, and that can happen only if we're intellectually and emotional mature enough to understand that it means cutting up bodies.
Mortality wasn't always a taboo subject, the body not always an object of perfect reverence to be untouched even as it was lowered into the ground. It's sort of ironic that we're more sensitive to the absent needs of the dead and presume the emotional fragility of the survivors than to our own needs as the living.
Mortality wasn't always a taboo subject, the body not always an object of perfect reverence to be untouched even as it was lowered into the ground. It's sort of ironic that we're more sensitive to the absent needs of the dead and presume the emotional fragility of the survivors than to our own needs as the living.
14
His language is fine. Describing in clinical terms what they did is preferable to obscuring the story with euphemisms. Medicine is not for the faint of heart.
11
We "avoid autopsies" because we don't get paid to do them, not because we are squeamish.
"Splayed out" is correct terminology when your target audience is physicians. The NYTimes readership, is comprised of individuals with varied spiritual practices. Have some tact.
It is a matter of RESPECT- not deference to "emotional fragility," that we should approach the topic with the same care that we give to a living version of that tissue.
"Splayed out" is correct terminology when your target audience is physicians. The NYTimes readership, is comprised of individuals with varied spiritual practices. Have some tact.
It is a matter of RESPECT- not deference to "emotional fragility," that we should approach the topic with the same care that we give to a living version of that tissue.
4
Most doctors, hospitals and their insurance companies would rather cover-up negligence than reap huge societal benefits from autopsies. I wouldn't even trust the hospital pathologist, an employee with a conflict of interest, in cases where hospital/doctor negligence is suspected. I recommend people choose an independent pathologist in their area.
I have personally called in an independent pathologist to retrieve a body from a hospital, an uncomfortable and confrontational situation, after a sudden and bizarre 6 hours, where an interventional cardiologist misdiagnosed someone in my family who presented to the hospital just hours before. Their misdiagnoses led the doctor to ultimately perform an unnecessary procedure that killed her because the procedure was contraindicated for her actual condition.
Maintain your composure and demand an independent autopsy.
I have personally called in an independent pathologist to retrieve a body from a hospital, an uncomfortable and confrontational situation, after a sudden and bizarre 6 hours, where an interventional cardiologist misdiagnosed someone in my family who presented to the hospital just hours before. Their misdiagnoses led the doctor to ultimately perform an unnecessary procedure that killed her because the procedure was contraindicated for her actual condition.
Maintain your composure and demand an independent autopsy.
78
I am an old physician in hematology & oncology. I remember the period when autopsies were routine. And it had a tremendous impact on the quality of the medicine we perform and on physician's insight. In American medicine we are under pressure to cut cost and cut time. We limit the tests we run making simplistic conclusions that we can get by with less. I had a patient who was a scientists with diarrhea. He had been evaluated extensively at a major university hospital but he still died without a diagnosis. An autopsy found worms, Strongyloides an easily treated disease that had been missed by every tests. The quality of American medicine has been seriously compromised by the pressure to cut costs. We make seemingly sound conclusions but in fact compromise patient care on too many levels.
83
This sounds like a "penny wise, pound foolish" situation. To save a little on autopsies probably results in further errors in diagnosis which can cause a lot in money, lives and suffering. Probably not all that many Americans are parasitized, but it's not impossible, either, as this particular autopsy determined. What we really need is the awareness that things like this CAN happen, and that would result from more frequent autopsies, and the spread of their information, particularly in cases of unexpected outcomes.
8
I disagree only slightly. The pressure in American medicine is not to cut costs, but to increase profits for various medicine-related industries. There is a tremendous amount of waste in medicine, e.g., administrative busy work, excessive procedures, ridiculous pricing for pharmaceuticals, etc., stuff that adds little value to quality of care. Concurrently there are woefully insufficient resources for work that could significantly increase quality of care. Moreover, the focus is on short-term profits only especially since nobody is really invested in long-term patient outcomes. Insurance policies are changed every year and government budgets are reshuffled with the election cycles.
Yes, autopsies should come back, and they should be done by independent entities. We need hard metrics for evaluating quality of medical care.
Yes, autopsies should come back, and they should be done by independent entities. We need hard metrics for evaluating quality of medical care.
24
Been there, thank god for Camera endoscopy . Physicians today rely on stool samples. Any farmer knows one stool sample is usually worthless ,worms have to be shedding eggs for stool samples to be valid therefore at least 3 tries on different weeks. when I share that with my Physician friends they look at me with that blank stare"thats not what we learned in school"
So folks insist on the camera endoscopy if you have weight loss and diarrhea.
Hookworms were once endemic in the southeastern US and they are back because we're not looking for them anymore. Yes you can get them from animals or from walking barefoot outside.
So folks insist on the camera endoscopy if you have weight loss and diarrhea.
Hookworms were once endemic in the southeastern US and they are back because we're not looking for them anymore. Yes you can get them from animals or from walking barefoot outside.
8
I have just one question: what other medical service should we forego to pay for all the additional autopsies proposed? We have limited resources, and most agree that America spends more than it should on medicine. (We spend far more than any other country.)
In my opinion, any discussion asking for medical expenditures above current levels *must* be accompanied by a proposal for where we should reduce spending. The notion that "financial considerations [should] not limit their use" is exactly how America ended up with a disastrously overpriced system of health care that creates a glut of specialists, shortages of general practitioners, and rationing by giving the poor substandard access to medicine. America's dysfunctional medical care is a case study in why medicine must not be exempt from considerations of financing.
So I ask: from where should we draw the funds for these autopsies? Should we do less of the medical tests you find inadequate? How about doing fewer life-saving surgeries for those who are don't have many healthy years left to live? Should we roll back coverage for mental health? Should we raise premiums and leave more uninsured? Should we cut taxes and decline to repair America's unsafe bridges and freeways?
It would be fabulous to live in a world where resources weren't limited, but alas it is not so. Unlike roads, autopsies don't increase economic activity, so the money *will* come from somewhere else.
In my opinion, any discussion asking for medical expenditures above current levels *must* be accompanied by a proposal for where we should reduce spending. The notion that "financial considerations [should] not limit their use" is exactly how America ended up with a disastrously overpriced system of health care that creates a glut of specialists, shortages of general practitioners, and rationing by giving the poor substandard access to medicine. America's dysfunctional medical care is a case study in why medicine must not be exempt from considerations of financing.
So I ask: from where should we draw the funds for these autopsies? Should we do less of the medical tests you find inadequate? How about doing fewer life-saving surgeries for those who are don't have many healthy years left to live? Should we roll back coverage for mental health? Should we raise premiums and leave more uninsured? Should we cut taxes and decline to repair America's unsafe bridges and freeways?
It would be fabulous to live in a world where resources weren't limited, but alas it is not so. Unlike roads, autopsies don't increase economic activity, so the money *will* come from somewhere else.
9
How about we cut the salaries of insurance CEOs? Or just eliminate their jobs entirely?
22
Better diagnosis might ultimately lessen the amount of testing and incorrect treatment, therefore lowering costs.
16
What should be cut out so that there can be autopsiess is the outrageous non medical costs of insurance and hospital administrative overhead.
24
Thank you for bringing attention to this. I had no idea that it could actually be difficult to request an autopsy until my husband died unexpectedly in January at age 55. It was obviously a cardiac event, but he had had no previous symptoms. I had many questions and especially wondered if this might be something important for my 9-year-old son's medical history, let alone my own peace of mind. Because the medical examiner didn't see a need for an autopsy, and because the death occurred in the ER (in the ER waiting room, to be specific), the hospital had no process in place to request an autopsy. It took hours of phone calls and tracking down the right people for signatures in person to make it happen--not how you want to spend your time in the hours after a tragic loss. Turns out my husband had two coronary arteries that were 80 percent blocked. That information can't change the outcome, but it's helpful to bring some closure on the horrible night. It seems that autopsies should be easily available whenever there are questions--for the purpose of improving medical treatment and helping families understand what happened.
49
Well said. As a retired physician, and raised in the 60's in medical school, we had no alternative but autopsies to figure out what we missed while the patient was alive. In today's world, we have so many more technological means to establish a diagnosis, at least indirectly. Still, an autopsy gives a wonderful direct view, supported by histopathology (among others), to call the shots. Let this practice come back, it will be of benefit to everybody, its cost notwithstanding.
45
Medical liability must also be a factor in the decline of autopsies. Finding a misdiagnosis may make for better doctors, but identifying otherwise unknown causes provides a malpractice lawyer with fresh opportunities.
I can understand why insurance won't pay. An autopsy does nothing to help the insured individual. Since the autopsy helps the greater good, it needs to be paid for in a way consistent with the greater good.
I can understand why insurance won't pay. An autopsy does nothing to help the insured individual. Since the autopsy helps the greater good, it needs to be paid for in a way consistent with the greater good.
48
Dr. Sandeep Jauhar writes "But none of us wanted to ask his grieving wife for permission."
When I was a young doctor in hospital, I found that explaining a) that finding out more about what killed their dear one and b) perhaps finding an unrelated problem which might prevent illness in another family member gave families some consolation and relief.
But it all began earlier, as a student in pathology class: we used a case example of a pathology report which was that of a medical student who asked that our professor do his autopsy and use the write-up as a learning tool
When I was a young doctor in hospital, I found that explaining a) that finding out more about what killed their dear one and b) perhaps finding an unrelated problem which might prevent illness in another family member gave families some consolation and relief.
But it all began earlier, as a student in pathology class: we used a case example of a pathology report which was that of a medical student who asked that our professor do his autopsy and use the write-up as a learning tool
13
Dr. Ronat, I'm an 83 year-old retired professor of medicine who agrees with you 100%.
During my education and training in the 1950s and early -60s, we were required to request permission for autopsies in every case of death in hospital. Indeed, hospitals were evaluated in part by autopsy rates.
On the first night of my internship (1958), there were two deaths on my service following cardiac surgeries that had been performed as last-ditch attempts on patients who were terminally ill. In both cases, permission was granted, in part because the families understood that in those early days of such attempts, many of which would now be regarded as experimental, the accumulating experience could lead to better chances of survival for patients yet to come. It would be through postmortem examination that the surgeon, who attended the autopsy, would learn how to modify the procedure in future cases. I of course learned as well.
During that year, my rate of receiving permission for autopsy was better than 95%, as I recall, and one stands out for me.
The deceased patient had already been taken to a funeral home in a city 60 miles away. I had not received permission for an autopsy. The following morning I received a call; the family had decided to allow examination of the heart - someone could drive down and retrieve it.
My professor asked me and a medical student to do the job; we were received graciously and did as we were sent to do. The procedure, modified, is now routine.
During my education and training in the 1950s and early -60s, we were required to request permission for autopsies in every case of death in hospital. Indeed, hospitals were evaluated in part by autopsy rates.
On the first night of my internship (1958), there were two deaths on my service following cardiac surgeries that had been performed as last-ditch attempts on patients who were terminally ill. In both cases, permission was granted, in part because the families understood that in those early days of such attempts, many of which would now be regarded as experimental, the accumulating experience could lead to better chances of survival for patients yet to come. It would be through postmortem examination that the surgeon, who attended the autopsy, would learn how to modify the procedure in future cases. I of course learned as well.
During that year, my rate of receiving permission for autopsy was better than 95%, as I recall, and one stands out for me.
The deceased patient had already been taken to a funeral home in a city 60 miles away. I had not received permission for an autopsy. The following morning I received a call; the family had decided to allow examination of the heart - someone could drive down and retrieve it.
My professor asked me and a medical student to do the job; we were received graciously and did as we were sent to do. The procedure, modified, is now routine.
6
You are correct, of course, Dr. Jauhar. Yet many people are reluctant to permit an autopsy, mainly because the idea of their loved one being dissected is horrible, even when one knows that the deceased is beyond any feeling. As you yourself state, "...the splayed-out tissues of an autopsy." is not something most laypeople can contemplate dispassionately. Recently the family of Justice Scalia did not wish an autopsy to be performed, since they knew that he had had several health issues, and there apparently was no mystery as to how he died. The case you cite, of the death of an infant, provides a clearer path to permitting an autopsy.
And the insurance companies care only about their bottom line, not about preventing future deaths.
And the insurance companies care only about their bottom line, not about preventing future deaths.
21
Dr Sandeep Jauhar fails to mention that another reason for the declining rate of autopsies is the fear of lawsuits .
Most of last autopsies i performed were demanded by relatives with "suing the Doctor" in mind.
The physicians sometimes were reluctant to get an autopsy for that very reason.
" we no longer want to know what we missed" knowing there are lots of ambulance chasers waiting in the wings.
Usha Shah MD. Retired Pathologist
Most of last autopsies i performed were demanded by relatives with "suing the Doctor" in mind.
The physicians sometimes were reluctant to get an autopsy for that very reason.
" we no longer want to know what we missed" knowing there are lots of ambulance chasers waiting in the wings.
Usha Shah MD. Retired Pathologist
41
I strongly support Dr. Jauhar's arguments. For me, autopsies on both of my parents revealed useful information that has given me comfort. When my father died, it was sudden, and as a result of undiagnosed intestinal ulcers that bled out after treatment with coumadin for another condition. I felt horrible, because I believed he might have had a few more years. Yet the autopsy revealed an undiagnosed cancer, which would have made those few years increasingly painful. His autopsy brought me peace of mind. In my mother's case, she spent her last few years in nursing care with profound dementia that left her totally uncommunicative. No one could say what form of dementia it was, until a brain autopsy revealed a rare form called CBGD. Consulting with an expert afterward helped me understand that this was not the much more common Alzheimer's, or even Lewi Body dementia, and that, given other details, it was unlikely to be hereditary -- giving both my children and me peace of mind, but also helping doctors understand how her often-mysterious symptoms correlated with her disease. I plan to require my family to have an autopsy on my body when I die, regardless of the circumstances. I've been an educator all my life; there is no reason why I cannot continue to be one in death.
69
Totally agree. In my training as an internal medicine resident at Dartmouth-Mary Hitchcock we were expected to ask. I think I "missed" only one "post" in my 3 years there. Families are usually amenable to the argument that, like organ donation, death can be an opportunity to help someone else and that the autopsy can be a good learning opportunity. I also try to take my clerks/residents to the autopsy - most, unbelievably, have never seen one and the pathologist, in lonely isolation, is usually delighted to see us!
31
In some cases, families who resist autopsy may simply be recoiling from the perceived horrors of body mutilation of their loved one.
However, in other cases there may be the feeling that nothing good can come to the family at that point from knowing the exact cause of death. That was the case in our family. We were "offered" an autopsy after a loved one died in the ICU a couple days following major open heart surgery. In our pain, we really didn't want to face the possibility of an autopsy outcome saying our doctor had made some type of blunder, or that the treatment decisions we participated in were ill-considered. That would have just meant more pain and guilt. No, we just wanted to go home to sleep and cry.
If the hospital had told us they needed the information from the autopsy to improve their knowledge for the future, I don't know if we would have been swayed at that point or not. But they didn't.
However, in other cases there may be the feeling that nothing good can come to the family at that point from knowing the exact cause of death. That was the case in our family. We were "offered" an autopsy after a loved one died in the ICU a couple days following major open heart surgery. In our pain, we really didn't want to face the possibility of an autopsy outcome saying our doctor had made some type of blunder, or that the treatment decisions we participated in were ill-considered. That would have just meant more pain and guilt. No, we just wanted to go home to sleep and cry.
If the hospital had told us they needed the information from the autopsy to improve their knowledge for the future, I don't know if we would have been swayed at that point or not. But they didn't.
12
Clearly, the question of payment is key to having more autopsies done. I also do wonder, though, if many hospitals - not necessarily the doctors and other medical staff - are happy enough to avoid a close look at patients who have died in their care, out of fear that they might be held accountable.
I also think that for every one family who is upset by the suggestion that an autopsy might reveal more information; there will be double that who want to understand what happened to cause the death.
I also think that for every one family who is upset by the suggestion that an autopsy might reveal more information; there will be double that who want to understand what happened to cause the death.
26
I agree; potential litigation over incorrect diagnoses is a likely reason why autopsies aren't being done.
15